Healthcare HealthTree Starter Kit

Healthcare HealthTree Starter Kit

The Healthcare HealthTree Starter Kit collects demographic, insurance and limited medical history information for the purpose of assembling a consolidated health summary, facilitating care coordination, and enabling authorized information exchange among the patient's care team. Complete all applicable fields. All information provided will be treated in accordance with applicable privacy laws and the organization's privacy practices.

Patient Information

Insurance Information

Medical History

HealthTree Starter Kit — Description and Uses

The HealthTree Starter Kit compiles provided demographic and clinical data into a concise health summary and recommended care checklist. Materials generated may include a problem list, medication reconciliation, care team contact list, and suggested next steps for follow-up care. These materials are intended to support clinical decision-making and patient self-management. The Starter Kit does not replace professional medical evaluation or emergency care.

Consent to Collect, Use and Disclose Health Information

By checking the box below I authorize the organization to collect, compile, and disclose my protected health information (PHI) as described below for the purposes of care coordination, treatment planning, treatment outcomes analysis, and secure transmission to my identified care providers. This authorization includes past, present and future health information necessary to create the Starter Kit materials.

Specific categories of information authorized: medical history, medication lists, allergies, diagnostic results, provider notes, and insurance information as reasonably necessary to prepare the Starter Kit. Recipients may include my identified health care providers, health information exchanges, and designated care team members.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices that describes how my protected health information may be used and disclosed, and how I can access this information. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy law.

Authorization to Obtain and Release Records

I authorize the organization and its agents to request and receive copies of my medical records from other healthcare providers and facilities as necessary to prepare the Starter Kit. I authorize release of the compiled Starter Kit and relevant source records to the individuals or entities I designate below.

Expiration, Revocation, and Rights

This authorization will expire on the date specified below or, if no date is specified, will remain in effect until revoked in writing. I understand I may revoke this authorization at any time by delivering a written notice of revocation to the organization, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures previously made in reliance on this authorization where the recipient has not taken action to return or destroy the information.

Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand the risks and benefits of authorizing the release and disclosure of my protected health information as described above, and I understand that I may revoke this authorization as described in this form.

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